How to File a Medicare Claim Yourself

A Medicare claim is a formal request for payment submitted to Medicare for healthcare services or supplies received. While healthcare providers typically handle this process, there are specific situations where a beneficiary might need to file a claim directly. Understanding this process ensures that individuals can seek reimbursement for eligible expenses, particularly when their provider does not submit claims on their behalf.

When Claims Are Filed

Medicare beneficiaries generally rely on their healthcare providers to submit claims for services rendered. However, direct beneficiary filing becomes necessary in certain situations. This often occurs when a provider does not accept Medicare assignment, meaning they do not agree to accept the Medicare-approved amount as full payment. Such providers may require upfront payment, making the beneficiary responsible for seeking reimbursement from Medicare.

Another scenario involves providers not enrolled in Medicare or those who refuse to submit claims on behalf of the patient. In these instances, the beneficiary must file the claim themselves. Medicare claims must be filed within 12 months from the date services were provided. If a claim is not submitted within this timeframe, Medicare may not pay its share, and the financial responsibility could fall entirely on the beneficiary.

Gathering Information for a Claim

Before filing a Medicare claim, gather all necessary information and documentation. A crucial document for this process is the CMS-1490S form, also known as the “Patient’s Request for Medical Payment.” This form can be downloaded from the Medicare website or obtained by calling Medicare directly.

To accurately complete the CMS-1490S form, several pieces of information are required. You will need your full name and Medicare number as they appear on your Medicare card, your current mailing address and telephone number, and details about the illness or injury for which treatment was received, including whether it was related to employment or an accident.

You will also need the healthcare provider’s name, address, and National Provider Identifier (NPI). Most importantly, an itemized bill from the provider is essential. This bill should clearly list the date of each service, a description of the medical or surgical service or supply furnished, and the charge for each service. If you have other health insurance coverage in addition to Medicare, such as private insurance or Medicaid, you must also include details about that coverage, including the policy number and the name and address of the other insurer. The itemized bill does not need to be paid before submitting the claim, but it must be attached for Medicare to process the request.

Submitting Your Medicare Claim

Once the CMS-1490S form is completed and all supporting documents are gathered, submit the claim to Medicare. The completed form, itemized bill, and any other relevant attachments must be mailed to the correct Medicare Administrative Contractor (MAC). These contractors process claims for specific geographic regions.

To find the appropriate mailing address for your MAC, refer to the Medicare Administrative Contractor Address Table, often included with the CMS-1490S form instructions. If unsure, call 1-800-MEDICARE for assistance. Make copies of the completed CMS-1490S form, itemized bill, and all other supporting documents for your records before mailing. Sending the submission via certified mail with a return receipt can provide proof of mailing and delivery.

After Filing: What to Expect

After submitting your Medicare claim, you can monitor its progress. Check the status by logging into your secure Medicare account online or by calling 1-800-MEDICARE. Claims are generally visible online within 24 hours after Medicare processes them.

Medicare will send a “Medicare Summary Notice” (MSN) every three to four months if you have received services covered by Medicare Part A and/or Part B during that period. The MSN is not a bill, but a detailed statement showing all services or supplies billed to Medicare on your behalf. It outlines what the provider charged, what Medicare paid, and the maximum amount you may owe. Reviewing your MSN verifies the accuracy of services and amounts paid, and serves as a record of your healthcare activity.

If a claim is denied or you disagree with the payment amount, you have the right to appeal the decision. Instructions for filing an appeal are typically included on the MSN. The appeals process involves several levels, beginning with a redetermination by a Medicare Administrative Contractor. If you are not satisfied with the outcome at one level, you can proceed to the next.